ANNALES KINESIOLOGIAE • 16 • 2025 • 1 61 Review article DOI: https://doi.org/10.35469/ak.2025.503 received: 2025-05-13 UDC: 616.12-053.2:796.011.1 PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN AT CARDIOVASCULAR RISK: A SYSTEMATIC REVIEW Katherine Estephani CONTRERAS-ZAPATA¹,², Sebastián Eustaquio MARTÍN-PÉREZ1,³,⁴, Nadia Ximena CRUZ-HIDALGO², Alejandro RUBIO-ZARAPUZ1, Vicente Javier CLEMENTE-SUÁREZ1, Isidro Miguel MARTÍN-PÉREZ⁴ 1 Faculty of Medicine, Health and Sports, Universidad Europea de Madrid, Spain 2 Grupo de Estudios en Educación, Actividad Física y Salud (GEEAFyS) Universidad Católica del Maule, Talca, Chile 3 Faculty of Health Sciences, Universidad Europea de Canarias, Santa Cruz de Tenerife, Spain 4 Escuela de Doctorado y Estudios de Posgrado, Universidad de La Laguna, Santa Cruz de Tenerife, Spain Corresponding authors: Katherine Estephani CONTRERAS-ZAPATA Master’s Degree in Research in Physical Activity and Sport Sciences, Faculty of Medicine, Health and Sports, Universidad Europea de Madrid, Villaviciosa de Odón, 28670, Madrid, Spain Phone: +(56)939280206 E-mail: 224a1818@live.uem.es Sebastián Eustaquio MARTÍN PÉREZ Faculty of Health Sciences, Universidad Europea de Canarias, 38300, La Orotava, Santa Cruz de Tenerife, Spain Phone: +349090817166 E-mail: sebastian.martin@universidadeuropea.es mailto:224a1818@live.uem.es mailto:sebastian.martin@universidadeuropea.es 62 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 ABSTRACT Introduction: Structured physical activity and lifestyle changes are promising strategies to reduce cardiovascular risk in children and adolescents. We hypothesize that programs meeting the minimum thresholds of frequency and duration—particu- larly those combining aerobic and resistance components—can significantly lower the blood pressure in at-risk pediatric populations. Purpose: To synthesize current evidence on the effectiveness of aerobic, resistance, and combined exercise interventions, alongside lifestyle modifications, in reducing car- diovascular risk among children and adolescents. Methods: A systematic review was conducted following PRISMA guidelines (PROSPERO CRD42025644256). Searches covered January 2015 to March 2025 across MEDLINE (PubMed), SPORTDiscus (EBSCO), and the Cochrane Library. The included studies were RCTs or quasi-experimental designs integrating exercise with di- etary or behavioral components. The primary outcomes were blood pressure, lipid pro- file, body composition, physical fitness, and health-related quality of life. Study quality was assessed using the PEDro scale and Cochrane RoB 2.0 tool. Results: Twenty-six studies (mean PEDro score: 9.9/10) met the inclusion criteria. Combined aerobic and resistance training with nutritional or behavioral support led to reductions in systolic/diastolic BP (–5 to –8 mmHg), body fat (–2 to –4%), and cholesterol (–10 to –15 mg/dL), alongside gains in aerobic capacity. Interventions in- volving families and school personnel showed greater adherence and cardiometabolic improvements. Conclusions: Integrated physical activity and lifestyle programs are effective at reducing cardiovascular risk markers in pediatric populations. Early implementation in supportive environments is essential for long-term health benefits. Keywords: physical activity, cardiovascular risk, hypertension, obesity, pediatric, lifestyle interventions TELESNA DEJAVNOST IN INTERVENCIJE V ŽIVLJENJSKI SLOG PRI OTROCIH S SRČNO-ŽILNO OGROŽENOSTJO: SISTEMATIČNI PREGLED IZVLEČEK Uvod: Strukturirana telesna dejavnost in spremembe življenjskega sloga so obetav- ne strategije za zmanjšanje srčno-žilne ogroženosti pri otrocih in mladostnikih. Naša hipoteza je, da lahko programi, ki dosegajo minimalne meje pogostosti in trajanja 63 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 (predvsem taki, ki združujejo aerobne elemente in elemente vadbe proti uporu), po- membno znižajo krvni tlak pri ogroženih pediatričnih populacijah. Namen: Strniti trenutne dokaze o učinkovitosti posegov v obliki aerobne vadbe, vadbe proti uporu in kombinirane vadbe skupaj s spremembami življenjskega sloga za zmanjšanje srčno-žilne ogroženosti pri otrocih in mladostnikih. Metode: Sistematični pregled je bil izveden v skladu s smernicami PRISMA (PROSPERO CRD42025644256). Iskanja so zajemala obdobje od januarja 2015 do marca 2025 v bazah MEDLINE (PubMed), SPORTDiscus (EBSCO) in Cochrane Library. Vključene so bile študije z randomiziranim kontroliranim poskusom (RKP) ali kvazieksperimentalno zasnovo, ki so združevale vadbo s prehranskimi ali vedenjskimi komponentami. Primarni izidi so bili krvni tlak, lipidni profil, telesna sestava, telesna pripravljenost in kakovost življenja, povezana z zdravjem. Kakovost študij je bila oce- njena z uporabo lestvice PEDro in orodja Cochrane RoB 2.0. Rezultati: Šestindvajset študij (povprečna ocena PEDro: 9,9/10) je izpolnjevalo merila izbora. Kombiniranje aerobne vadbe in vadbe proti uporu s prehransko ali ve- denjsko podporo je privedlo do znižanja sistoličnega/diastoličnega krvnega tlaka (–5 do –8 mmHg), telesne maščobe (–2 do –4 %) in holesterola (–10 do –15 mg/dL) in iz- boljšanja aerobne zmogljivosti. Posegi, pri katerih so sodelovali družine in šolsko ose- bje, so se izkazali za doslednejše, privedli pa so tudi do kardiometabolnega izboljšanja. Zaključki: Integrirani programi telesne dejavnosti in sprememb življenjskega sloga so učinkoviti pri zmanjševanju kazalnikov tveganja za srce in ožilje pri pediatrični po- pulaciji. Njihovo zgodnje uvajanje v podpornih okoljih je ključno za dolgoročne koristi za zdravje. Ključne besede: telesna dejavnost, srčno-žilna ogroženost, hipertenzija, debelost, pediatrična populacija, intervencije v življenjski slog 64 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 INTRODUCTION Non-communicable diseases (NCDs) account for the majority of global morbidity and mortality, driven by a complex interplay of genetic, physiologi- cal, environmental, and psychosocial factors. Among these, arterial hyperten- sion (HTN) is particularly insidious: often silent and asymptomatic (Falkner et al., 2023), it nonetheless accelerates atherosclerotic processes and substan- tially elevates both coronary and cerebrovascular risk throughout the life- span (Benenson, Waldron, & Porter, 2020; Bull et al., 2020; Ferrer-Arrocha, Fernández Rodríguez, & González Pedroso, 2020; Llapur-Milián & González- Sánchez, 2017; Lurbe, Fernandez-Aranda, & Wühl, 2021; Hernández- Magdariaga et al., 2023). Although historically considered an adult condition, compelling evidence now demonstrates that the pathogenesis of HTN frequently begins in childhood or adolescence (Stephens, Fox, & Maxwell, 2012). In pediatric populations, elevated blood pressure is underdiagnosed—routine screening is uncommon and early elevations remain subclinical—yet even mild, sustained increases in systolic or diastolic pressure significantly amplify the lifetime cardiovascular risk (González-Sánchez et al., 2015; Xi et al., 2017; Venegas-Rodríguez, Vitón- Castillo, Linares-Cánovas, Díaz-Pita, & Álvarez-Alvarez, 2021). Established pediatric risk factors include excess adiposity, physical inactivity, and seden- tary behavior; overweight or obese children are up to five times more likely to develop HTN and its complications than their normal-weight peers. Data from the American Heart Association indicates that approximately 15 % of adolescents with systolic BP ≥ 120 mmHg or diastolic BP ≥ 80 mmHg already exhibit subclinical coronary or cerebrovascular injury (Lloyd-Jones et al., 2011), and left ventricular hypertrophy can be detected within one year of pediatric HTN diagnosis (Rosas-Peralta et al., 2016). While pharmacolo- gical treatments—ACE inhibitors, angiotensin II receptor blockers, and diu- retics—effectively lower the blood pressure, their long-term use in children is hampered by metabolic side effects, dose titration requirements, adherence challenges, and potential psychosocial impacts (Cohen & Wills., 1985; Lurbe et al., 2010; de la Cerda & Herrero, 2014; Weaver Jr, 2019). In recent years, structured physical activity and comprehensive lifestyle mo- difications have emerged as promising non-pharmacological strategies for both the prevention and management of cardiovascular risk in the pediatric popula- tion (Briones-Arteaga, 2016; Budts et al., 2020; Tozo et al., 2025; Williams, et al., 2019). While aerobic, resistance, and combined exercise programs have de- monstrated significant reductions in systolic and diastolic blood pressure among 65 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 children and adolescents, the available evidence remains inconsistent and fra- gmented. Specifically, the optimal “dose” of exercise—defined by intensity, frequency, and duration—has not been clearly established, the relative efficacy of different exercise modalities is still up for debate, and effective strategies to ensure long-term adherence in young populations are largely lacking (del Valle Soto et al., 2015; Durán Parrondo, & Rueda Núñez, 2020; Gamero, Idarreta & Vargas, 2022). In this context, we hypothesized that structured physical activity interventions can significantly reduce systolic and diastolic blood pressure in children and adolescents with elevated cardiovascular risk, provided that mini- mum thresholds of frequency and duration are met. Therefore, the objective of this systematic review is to critically synthesize the available evidence on the effectiveness of aerobic, resistance, and combi- ned exercise interventions, along with complementary lifestyle modifications, at reducing cardiovascular risk among children and adolescents. The review also aims to determine the optimal exercise parameters (intensity, frequency, and duration) and to develop practical and age-appropriate recommendations. MATERIALS AND METHODS Data Sources and Search Strategy A systematic literature review was conducted following the PRISMA gu- idelines (Page et al., 2021). The review protocol was previously registered in PROSPERO (CRD42025644256, https://www.crd.york.ac.uk/PROSPERO/ view/CRD42025644256). The literature search was performed from January 28, 2025, to March 30, 2025, aiming to find relevant studies on the effecti- veness of physical activity and lifestyle interventions for cardiovascular risk in children. Afterward, the databases searched included MEDLINE (PubMed), SPORTDiscus (EBSCO), and the Cochrane Library. In MEDLINE, the fol- lowing search strategy was applied: – Population terms: “Children” OR “Adolescents” OR “Pediatric Population” AND (“Cardiovascular Risk” OR “Hypertension” OR “Obesity” OR “Metabolic Syndrome”). – Intervention terms: (“Physical Activity” OR “Exercise Therapy” OR “Aerobic Exercise” OR “Strength Training” OR “Lifestyle Modification” OR “Combined Interventions”). https://www.crd.york.ac.uk/PROSPERO/view/CRD42025644256 https://www.crd.york.ac.uk/PROSPERO/view/CRD42025644256 66 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Ta bl e 1. S ea rc h st ra te gy D at e D at ab as e Se ar ch T er m s Se ar ch E qu at io n 20 25 -0 2- 20 M ED LI N E (P ub M ed ) “C ar di ov as cu la r r is k” , “ hy pe rte ns io n” , “p hy si ca l a ct iv ity ”, “ lif es ty le in te rv en tio ns ”, “c hi ld re n” („ ca rd io va sc ul ar ri sk “ O R „ hy pe rte ns io n“ ) A N D („ ph ys ic al a ct iv ity “ O R „ ex er ci se “) A N D („ lif es ty le in te rv en tio ns “) A N D („ ch ild re n“ ) 20 25 -0 2- 20 M ED LI N E (P ub M ed ) “O be si ty ”, “ lif es ty le c ha ng es ”, “ ph ys ic al ex er ci se ”, “ ad ol es ce nt s” („ ob es ity “) A N D („ lif es ty le c ha ng es “ O R „ ph ys ic al ex er ci se “) A N D („ ad ol es ce nt s“ ) 20 25 -0 2- 20 M ED LI N E (P ub M ed ) “F itn es s” , “ ca rd io va sc ul ar d is ea se ”, “c hi ld re n” , “ lif es ty le c ho ic es ” („ fit ne ss “) A N D („ ca rd io va sc ul ar d is ea se “) A N D („ ch ild re n“ ) A N D („ lif es ty le c ho ic es “) 20 25 -0 2- 22 M ED LI N E (P ub M ed ) “E xe rc is e” , “ hy pe rte ns io n” , “ m et ab ol ic sy nd ro m e” , “ te en ag er s” („ ex er ci se “) A N D („ hy pe rte ns io n“ O R „ m et ab ol ic sy nd ro m e“ ) A N D („ te en ag er s“ ) 20 25 -0 2- 28 M ED LI N E (P ub M ed ) “P hy si ca l a ct iv ity ”, “ ch ild ho od o be si ty ”, “l ife st yl e m od ifi ca tio n” („ ph ys ic al a ct iv ity “) A N D („ ch ild ho od o be si ty “) A N D („ lif es ty le m od ifi ca tio n“ ) 20 25 -0 3- 02 SP O RT D is cu s (E B SC O ) “C ar di ov as cu la r d is ea se ”, “ ch ild re n” , “p hy si ca l a ct iv ity ”, “ ex er ci se ” („ ca rd io va sc ul ar d is ea se “) A N D („ ch ild re n“ ) A N D („ ph ys ic al a ct iv ity “ O R „ ex er ci se “) 20 25 -0 3- 22 SP O RT D is cu s (E B SC O ) “O be si ty , “ ph ys ic al a ct iv ity ”, “ yo ut h” , “l ife st yl e in te rv en tio ns ” („ ob es ity “) A N D („ ph ys ic al a ct iv ity “) A N D („ yo ut h“ ) A N D („ lif es ty le in te rv en tio ns “ O R „ lif es ty le c ha ng es “) 20 25 -0 3- 30 SP O RT D is cu s (E B SC O ) “P hy si ca l fi tn es s” , “ ex er ci se ”, “ te en ag er s” , “c ar di ov as cu la r r is k” („ ph ys ic al fi tn es s“ O R „ ex er ci se “) A N D („ te en ag er s“ ) A N D („ ca rd io va sc ul ar ri sk “) 20 25 -0 2- 27 C oc hr an e Li br ar y “H yp er te ns io n” , “ ob es ity ”, “ ph ys ic al ex er ci se ”, “ sy st em at ic re vi ew ” („ hy pe rte ns io n“ O R „ ob es ity “) A N D („ ph ys ic al ex er ci se “) A N D („ sy st em at ic re vi ew “) A N D N O T „r ev ie w “ 20 25 -0 3- 27 C oc hr an e Li br ar y “C ar di ov as cu la r r is k” , “ lif es ty le in te rv en tio ns ”, “ ex er ci se ”, “ ch ild re n” („ ca rd io va sc ul ar ri sk “) A N D („ lif es ty le in te rv en tio ns “ O R „ ex er ci se “) A N D („ ch ild re n“ ) 67 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 – Additional terms: “Hypertension” [Mesh], “Exercise” [Mesh], “Lifestyle” [Mesh], “Obesity” [Mesh], and keywords like “Exercise in- tervention”, “Cardiovascular risk”, and “pediatric”. Similar search strategies were applied to SPORTDiscus (EBSCO) and the Cochrane Library. Three independent researchers (SMP, IMP, and ARZ) con- ducted the searches, and a fourth researcher (VJS), blinded to the process, revi- ewed all the articles by title and abstract. Selected articles underwent a full-text review for eligibility. The detailed search strategy is shown in Table 1. Search strategy. Study Selection The inclusion criteria for the systematic review and meta-analysis were as follows: 1. Randomized, non-randomized, or quasi-experimental clinical trials, case series, and case reports. 2. Studies published between January 1, 2015, and March 30, 2025. 3. Studies published in English, Spanish, or Portuguese. 4. Availability of full-text articles. 5. Studies involving children or adolescents (ages 5–17) with cardiovascu- lar risk (hypertension, obesity or metabolic syndrome). 6. Participants in physical-activity-based rehabilitation programs, with or without additional educational, psychological, or nutritional support. 7. Studies measuring physical functionality, metabolic parameters, and li- festyle-related outcomes (e.g., exercise, diet) as primary or secondary outcomes. Exclusion criteria included: 1. Non-original publications, such as conference presentations, abstracts, correspondence, and narrative reviews. 2. Duplicated or re-published studies. 3. Studies with significant methodological issues or low scientific rigor. 4. Studies with incomplete data or inaccessible information. Discrepancies were resolved using a standardized PICO (Population, Intervention, Comparison, Outcome) framework. One independent researcher (NCH) extracted all the relevant data, including authorship, year and country of publication, study design, objectives, measured outcomes, participant charac- teristics (e.g., sample size, sex, clinical status), details of the intervention and control groups, and main conclusions. The process adhered to the guidelines 68 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 outlined in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.1.0) (Higgins & Green, 2019). To ensure reliability, the data extracti- on table was piloted using a representative sample of included studies. Methodological Quality Assessment (PEDro Scale) The methodological quality of the included trials was assessed using the PEDro scale (Maher, Sherrington, Herbert, Moseley, & Elkins, 2003), consi- sting of 11 items evaluating internal validity (items 2–9) and statistical repor- ting (items 10–11). The studies were classified as follows: – Excellent quality: 9–10 points. – Good quality: 6–8 points. – Poor quality: <4 points. Risk of Bias Assessment (RoB 2.0) The risk of bias in randomized clinical trials was evaluated using the Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2.0) (Higgins et al., 2011), focusing on: – Randomization process. – Deviations from the intended interventions. – Missing outcome data. – Outcome measurement. – Selection of reported outcomes. A low risk of bias indicates a minimal potential impact on the study results, while a high risk reduces confidence in the findings. Discrepancies between reviewers were resolved through discussion, with final decisions made by a third reviewer (SMP). 69 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 RESULTS Study Selection A total of 740 records were identified through database searches, including 272 from MEDLINE (PubMed), 6 from SPORTDiscus (EBSCO), and 462 from the Cochrane Library. After removing 481 records due to duplication, irrelevant titles or abstracts, or failure to meet the initial inclusion criteria, 259 studies were retained for screening. Of these, 108 were excluded after title and abstract review for reasons such as a focus on adult populations, lack of structu- red exercise interventions, or the absence of cardiovascular risk outcomes. The remaining 151 full-text articles were assessed for eligibility. A total of 125 studies were excluded at this stage: 22 due to ineligible stu- dy design (e.g., case reports, commentaries, or non-interventional studies), 12 for lacking quantifiable pre/post-intervention data, 6 for being observational studies without structured physical activity components, 8 for incomplete inter- vention or outcome reporting, and 77 for being secondary literature (e.g., nar- rative reviews, systematic reviews, meta-analyses, or bibliometric analyses). Ultimately, 26 studies met all the eligibility criteria and were included in the final systematic review. See Figure 1. Flow diagram of study selection accor- ding to PRISMA 2020. Characteristics of the Included Studies This systematic review included 26 studies, including randomized control- led trials (RCTs), quasi-experimental studies, and non-randomized trials, all aimed at assessing the impact of physical activity and lifestyle interventions on children and adolescents with cardiovascular risk factors, primarily focu- sing on obesity, hypertension, and metabolic syndrome. These studies were published between 2015 and 2025 and involved a variety of interventions, in- cluding exercise-based programs, diet modifications, and family- or school- based support (Aguilar-Cordero et al., 2020; Anderson et al., 2017; André & Béguier, 2015; Hossain et al., 2018; Jerome et al., 2022; Kalantari et al., 2017; Kokkvoll, Grimsgaard, Steinsbekk, Flægstad, & Njølstad 2015; Mameli et al., 2018; Malarvizhi & Pasupathy, 2023; Martí, Martínez, Ojeda-Rodríguez, & Azcona-Sanjulian, 2021; Morell-Azanza et al., 2019; Nayak & Bhat, 2016; Eggertsen et al., 2025; Ojeda-Rodríguez et al., 2021; Oreskovic, Winickoff, 70 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Figure 1: Flow diagram of study selection according to PRISMA 2020 Identification of studies via databases and registers In cl ud ed Sc re en in g Id en tifi ca tio n Records identified from: (n = 740) MEDLINE (PubMed) (n = 272) SPORT Discus (n = 6) Cochrance Library (n = 462) Records screened (n = 259) Studies included in the review (n = 26) Records excluded** after reading title and abstract (n = 108) Records removed before screening: duplicate records removed (n = 481) Reports excluded (n = 125): – Ineligible study design (e.g. case reports, commentaries, non- interventional trials) (n = 22) – No quantifiable pre-post intervention data on blood pressure or other cardiovascular outcomes (n = 12) – Observational studies without a structured physical activity intervention (n = 6) – Incomplete reporting of intervention protocols or outcome data (n = 8) – Secondary literature (e.g. narrative reviews, systematic reviews, bibliometric analyses, meta-analyses) (n = 77) Reports assessed for eligibility (n = 151) 71 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 Perrin, Robinson, & Goodman, 2016; Pamplona-Cunha, et al., 2022; Wesnigk et al., 2016; Wong, Sanchez-Gonzalez, Son, Kwak, & Park, 2018; Xu et al., 2020). The total number of participants across all the studies was approximately 3,500, with study populations ranging from small groups (n = 16) to large-scale (n = 6764). The participants’ ages ranged from 5 to 18 years, with a large num- ber of studies focusing on adolescents (10–17 years). Both boys and girls were included, with some studies providing gender-specific effects (Anderson et al., 2017; Mameli et al., 2018). Many of the studies (n = 20) were RCTs, ensuring an important level of evidence, while a few of them (n = 4) were quasi-experi- mental, and some (n = 2) were non-randomized controlled trials. These designs provided valuable insights into the efficacy of lifestyle changes in children and adolescents (Aguilar-Cordero et al., 2020; Hossain et al., 2018). The interventions tested in the studies varied in length, ranging from short- term programs (e.g., 8 weeks) to long-term interventions (up to 22 months). Most of the interventions focused on physical activity, including aerobic exercises, strength training, or combined programs, and were supplemented by nutritional guidance. Some studies also included behavioral support, such as Motivational Interviewing (MI) or educational programs aimed at impro- ving knowledge of healthy lifestyle choices. These interventions were often family-based or school-based, reflecting the importance of involving the fa- mily and community in promoting healthy habits (André & Béguier, 2015; Malarvizhi & Pasupathy, 2023; Morell-Azanza et al., 2019). Most of the studies used a control group, with some employing minimal- intensity or usual care groups, while others compared several types of inter- ventions (e.g., exercise only vs. exercise with diet). A few studies were used within-subject designs where the participants served as their own control, as- sessing changes before and after the intervention. The main outcomes measu- red included blood pressure (systolic and diastolic), body mass index (BMI), body fat percentage, physical fitness (e.g., aerobic capacity, muscle strength), and quality of life. Additional outcomes included metabolic parameters such as cholesterol levels, insulin sensitivity, and markers of inflammation (Arenaza et al., 2020; Malarvizhi & Pasupathy, 2023; Oreskovic et al., 2016). The follow-up periods varied across studies, with most measuring immedi- ate or short-term effects (≤ 12 weeks), while others had long-term follow-ups (12 months or more), allowing for an assessment of both immediate benefits and the sustainability of the interventions (Wesnigk et al., 2016; Wong et al., 2018). The methodological quality of the studies was generally high, with most reporting a PEDro score of 8 or above, showing good quality. The risk of bias 72 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 was assessed using the RoB 2.0 tool, and most studies showed a low to mode- rate risk. However, some studies had limitations in blinding and randomization procedures, which could have influenced the results (Kalantari et al., 2017; Kokkvoll et al., 2015). The studies were conducted in various countries, including Spain, the USA, New Zealand, Italy, and China, adding to the generalizability of the findings. However, cultural and contextual factors may influence the effectiveness of the interventions, as certain dietary habits and physical activity levels differ across regions (Nayak & Bhat, 2016; Wang, Lau, Wang, & Ma, 2015). Overall, the review found that the interventions, especially those combining physical acti- vity with nutritional modifications and behavioral support, significantly impro- ved cardiovascular risk factors such as blood pressure, body composition, and physical fitness. These findings underscore the importance of early interventi- ons and promoting healthy habits to prevent long-term cardiovascular diseases (Oreskovic et al., 2016; Pamplona-Cunha et al., 2022). Detailed information is presented in Table 2. 73 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 T ab le 2 . C ha ra ct er is tic s o f t he in cl ud ed st ud ie s St ud y C ou nt ry D es ig n Pa rt ic ip an ts D ur at io n In te rv en tio n C on tr ol O ut co m es C on cl us io ns A gu ila r- C or de ro e t a l., 20 20 Sp ai n R C T 98 o ve rw ei gh t/ ob es e ch ild re n (1 0. 43 ± 1 .3 5 ye ar s) 8 m on th s Pl ay -b as ed ph ys ic al a ct iv ity + nu tri tio na l ed uc at io n U su al c ar e H yp er te ns io n: 8 5. 7% → 1 6. 3% (p < 0 .0 01 ) SB P (p < 0 .0 01 ) D B P (p < 0 .0 01 ) B od y fa t % (p < 0. 00 1) Ph ys ic al a ct iv ity co m bi ne d w ith he al th y ea tin g si gn ifi ca nt ly re du ce s bl oo d pr es su re in ov er w ei gh t/o be se ch ild re n. A nd er so n et a l., 20 17 N ew Ze al an d U nb lin de d R C T 20 3 ch ild re n (5 –1 6 ye ar s) 12 m on th s M ul tid is ci pl in ar y lif es ty le p ro gr am M in im al - in te ns ity co nt ro l Δ B M I S D S: − 0. 35 v s −0 .1 4 (p < 0 .0 5) Q oL : 1 5. 6 ± 10 .2 v s 7. 9 ± 12 .3 (p < 0 .0 1) H ig h at te nd an ce in a m ul tid is ci pl in ar y pr og ra m y ie ld s si gn ifi ca nt B M I S D S re du ct io n an d be tte r qu al ity o f l ife . A nd ré & B ég ui er , 2 01 5 Fr an ce R C T 24 o be se ad ol es ce nt s ( 12 –1 7 ye ar s) N ot sp ec ifi ed PA + M ot iv at io na l In te rv ie w in g PA o nl y B M I: −1 .5 v s − 0. 9 (p < 0. 05 ) Se lf- effi ca cy : 7 .8 ± 2. 1 vs 5 .2 ± 2 .8 (p < 0. 01 ) In te gr at in g M I w ith P A e nh an ce s se lf- re gu la tio n an d lo ng -te rm b eh av io r ch an ge . A re na za e t a l., 20 20 Sp ai n Tw o- ar m R C T 81 o ve rw ei gh t/ ob es e ch ild re n (1 0. 6 ± 1. 1 ye ar s; 5 3% gi rls ) 22 w ee ks Fa m ily -b as ed he al th y lif es ty le + ex er ci se N o- ex er ci se co nt ro l K ID M ED : ↑ 5. 4 → 7. 7 (p < 0 .0 01 ); D A SH : ↑ 1. 1 → 1 .9 (p < 0. 00 1) En er gy ra tio : 0 .7 3 → 0. 61 (p < 0 .0 14 ) Fa m ily p ro gr am s im pr ov e di et q ua lit y; em ph as iz e re du ci ng su ga ry d rin ks a nd in cr ea si ng a ct iv ity . B ru yn do nc kx et a l., 2 01 5 B el gi um Q ua si - ra nd om iz ed tri al 61 o be se ad ol es ce nt s ( 12 –1 8 ye ar s) 10 m on th s R es id en tia l d ie t an d ex er ci se U su al c ar e B M I: −2 .2 v s − 0. 7 (p < 0. 01 ) B od y fa t % : − 5. 4% v s −1 .2 % (p < 0 .0 5) R es id en tia l d ie t a nd ex er ci se in te rv en tio n im pr ov es o be si ty m ar ke rs . 74 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 St ud y C ou nt ry D es ig n Pa rt ic ip an ts D ur at io n In te rv en tio n C on tr ol O ut co m es C on cl us io ns Eg ge rts en e t al ., 20 25 D en m ar k R C T 17 3 ob es e ch ild re n 12 m on th s Li fe st yl e w ith / w ith ou t H II T U su al c ar e B M I S D S: − 0. 20 (p < 0. 01 ) Pe ds Q L: + 6. 89 (p < 0. 01 ) H II T fe as ib le a nd im pr ov es a dh er en ce an d Q oL . H os sa in e t a l., 20 18 U SA R C T 21 a do le sc en ts (1 4– 18 y ea rs ; 1 5 ob es e, 6 le an ) N ot sp ec ifi ed Ph ys ic al a ct iv ity lif es ty le U su al c ar e 25 (O H )D : 1 2. 8 vs 9 .3 ng /m L (p = 0 .0 6) Fa t-f re e m as s: + 1. 5 kg v s + 0. 3 kg (p < 0. 05 ) PA im pr ov es v ita m in D st at us a nd le an m as s w ith ou t su pp le m en ta tio n. H ow ie e t a l., 20 15 A us tra lia W ith in - su bj ec t co nt ro lle d 56 o be se ad ol es ce nt s ( 11 –1 6 ye ar s) 8 w ee ks + 12 -m on th fo llo w -u p Pa re nt -le d se lf- de te rm in at io n + PA + n ut rit io n + ed uc at io n W ith in - su bj ec t co nt ro l 6M W T: + 48 .8 m (8 w k, p = 0 .0 18 ); +8 1. 3 m (1 2 m o, p < 0 .0 01 ) Q ua dr ic ep s: + 1. 1 kg ·F (p = 0 .0 30 ). D el to id s: + 1. 0 kg ·F (p = 0 .0 44 ) Sh or t-t er m p ro gr am yi el ds la st in g fit ne ss an d st re ng th g ai ns . Je ro m e et a l., 20 22 U SA Tw o- ar m R C T 10 0 ov er w ei gh t/ ob es e ad ol es ce nt s w ith A D H D (8 –1 8 ye ar s) 12 m on th s M V PA + d ie ta ry co un se lin g St an da rd A D H D ca re B M I ( 8– 12 y rs ): p = 0. 01 4 M V PA (8 –1 2 yr s) : p = 0. 01 2 Sc re en ti m e in cr ea se in B la ck p ar tic ip an ts : p = 0. 00 7 Pr om ot e PA a nd li m it sc re en ti m e in y ou th w ith A D H D . K al an ta ri et a l., 20 17 Ir an R C T 96 m al e ad ol es ce nt s (1 2– 16 y ea rs ) 12 w ee ks C om pr eh en si ve lif es ty le U su al c ar e B od y fa t % : − 1. 81 % (p < 0 .0 1) B M I: 24 .7 v s 2 5. 1 (p = 0. 10 ) 12 -w ee k lif es ty le pr og ra m re du ce s bo dy fa t i n m al e ad ol es ce nt s. K ok kv ol l e t a l., 20 15 N or w ay R C T 97 c hi ld re n (6 –1 2 ye ar s) N ot sp ec ifi ed M ul ti- fa m ily v s si ng le -f am ily Si ng le - fa m ily in te r- ve nt io n B M I: −1 .2 9 vs − 2. 02 kg /m ² ( p = 0. 07 5) W ai st c irc .: −2 .4 c m (p = 0 .0 38 ) M ul ti- fa m ily ap pr oa ch b en efi ts w ai st c irc um fe re nc e an d ps yc ho lo gy . 75 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 St ud y C ou nt ry D es ig n Pa rt ic ip an ts D ur at io n In te rv en tio n C on tr ol O ut co m es C on cl us io ns K le pp an g et a l., 20 24 N or w ay C lu st er - co nt ro lle d no n- ra nd om iz ed 12 6 ch ild re n (5 –1 3 ye ar s) N ot sp ec ifi ed Fa m ily -b as ed lif es ty le U su al c ar e H R Q oL : 5 0. 0 vs 4 9. 0 (p = 0 .8 9) Sl ee p ha bi ts : 4 5. 2 vs 46 .0 (p = 0 .9 2) N o si gn ifi ca nt im pr ov em en ts in Q oL o r s le ep . M am el i e t a l., 20 18 Ita ly R C T 30 o ve rw ei gh t/ ob es e ch ild re n (1 0– 17 y ea rs ) 3 m on th s Pe rs on al iz ed lif es ty le + ex er ci se a pp U su al c ar e B M I z -s co re : 0 .0 7 kg (C I 2 .8 1, 2 .9 6) N o si gn ifi ca nt w ei gh t l os s w ith a pe rs on al iz ed a pp . M al ar vi zh i & P as up at hy , 20 23 In di a R C T 14 5 ov er w ei gh t ch ild re n (1 1– 15 ye ar s) N ot sp ec ifi ed Sc ho ol -b as ed ex er ci se + nu tri tio n gu id el in es U su al cu rr ic ul um D is ta nc e: + 15 0 m (p < 0. 05 ) V O ₂ m ax : + 5. 3 m L/ kg /m in (p < 0 .0 1) Sc ho ol -b as ed in te rv en tio ns im pr ov e ex er ci se to le ra nc e. M ar tí et a l., 20 21 Sp ai n R C T 29 w ith a bd om in al ob es ity 2 m on th s + 10 -m on th fo llo w -u p In te ns iv e lif es ty le U su al c ar e LB P: 0 .9 µ g/ m L (p = 0. 03 3) C he m er in : 1 .3 n g/ m L (p = 0 .0 29 ) R ed uc tio ns in m et ab ol ic bi om ar ke rs su gg es t im pr ov ed ri sk . M or el l-A za nz a et a l., 2 01 9 Sp ai n R C T 10 6 w ith a bd om in al ob es ity 8 w ee ks M ul tid is ci pl in ar y lif es ty le U su al c ar e M V PA : + 5. 5 m in /d ay (p < 0 .0 5) Le pt in in ve rs el y co rr el at ed (p < 0 .0 5) B oo st s M V PA a nd lo w er s l ep tin in ob es e ch ild re n. M ox le y et a l., 20 19 U SA Q ua si - ex pe ri- m en ta l 88 4 ch ild re n/ ad ol es ce nt s ( 5– 17 ye ar s) N ot sp ec ifi ed Pa re nt -f oc us ed m en ta l, nu tri tio na l a nd ha bi t e du ca tio n Va rio us su bg ro up s B M I z -s co re (p < 0. 00 01 ) FF M a nd b od y fa t im pr ov em en ts (p < 0. 00 01 ) Fa m ily -in vo lv ed in te rv en tio ns im pr ov e bo dy co m po si tio n su st ai na bl y. N ay ak & B ha t, 20 16 In di a R C T 19 4 ov er w ei gh t/ ob es e ch ild re n 6 m on th s M ul tic om po ne nt lif es ty le U su al c ar e B M I: 24 .9 v s 2 2. 8 (p = 0. 03 4) Sk in fo ld s: si gn ifi ca nt re du ct io ns ; S el f- es te em im pr ov ed D ai ly v ig or ou s ex er ci se a nd h ea lth y ea tin g re du ce ad ip os ity a nd b oo st se lf- es te em . O je da - R od ríg ue z et al ., 20 21 Sp ai n R C T 12 1 ab do m in al ob es ity (7 –1 6 ye ar s) 22 m on th s Li fe st yl e pr og ra m U su al c ar e M V PA : + 5. 4 m in /d ay (p = 0 .0 35 ) Se de nt ar y +4 9. 7 m in / da y (c on tro l, p = 0. 01 0) In te ns iv e PA h el ps m ai nt ai n te lo m er e le ng th in o be se ch ild re n. 76 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 St ud y C ou nt ry D es ig n Pa rt ic ip an ts D ur at io n In te rv en tio n C on tr ol O ut co m es C on cl us io ns O re sk ov ic e t al ., 20 16 U SA Q ua si -R C T 60 a do le sc en ts (1 0– 16 y ea rs ) N ot sp ec ifi ed B ui lt- en vi ro nm en t co un se lin g + PA St an da rd co un se lin g M V PA : + 13 .9 v s − 0. 6 m in (T 2, p < 0 .0 00 1) ; +9 .3 v s + 0. 5 m in (T 3, p = 0. 00 06 ); ≥6 0 m in / da y: 2 1% v s 0 % C ou ns el in g en ha nc es M V PA in o be se ad ol es ce nt s. Pa m pl on a- C un ha e t a l., 20 22 B ra zi l R C T 11 4 ab do m in al ob es ity + dy sl ip id em ia (8 –1 4 ye ar s) N ot sp ec ifi ed PA + n ut rit io na l co un se lin g PA o nl y To ta l c ho le st er ol : −1 1% (p < 0 .0 01 ) LD L- c: − 19 % (p = 0. 00 2) B od y fa t: −5 .2 % N ut rit io na l co un se lin g pl us P A en ha nc es fa t a nd ri sk m ar ke r r ed uc tio n. W an g et a l., 20 15 C hi na C lu st er no n- ra nd om iz ed 43 8 ch ild re n (7 –1 2 ye ar s) N ot sp ec ifi ed D ie t + P A v s d ie t- on ly v s P A -o nl y D ie t-o nl y, PA -o nl y, co nt ro l B od y fa t % : − 1. 01 % (p < 0 .0 01 ) SB P: − 4. 37 m m H g (p < 0. 05 ) C om bi ne d pr og ra m ou tp er fo rm s d ie t- on ly a nd P A -o nl y. W an g et a l., 20 22 C hi na M ul ti- ce nt er cl us te r t ria l 30 ,9 97 in te rv en tio n; 27 ,4 77 c on tro l Sc ho ol ye ar Sc ho ol -b as ed he al th -li fe st yl e ed uc at io n U su al cu rr ic ul um K no w le dg e: 9 2. 17 % vs 9 0. 89 % B el ie fs : 7 1. 18 % v s 68 .6 1% Pr ac tic es im pr ov ed (p < 0. 05 ) Im pr ov es st ud en t kn ow le dg e an d pr ac tic es , n o sp ill ov er to p ar en ts / ad m in . W es ni gk e t a l., 20 16 G er m an y R C T 16 a do le sc en ts (1 5 ± 1 ye ar s; B M I > 35 ) 10 m on th s D ie ta ry re st ric tio n + ex er ci se U su al c ar e W ei gh t l os s: − 31 % (p < 0. 05 ) H D L eN O S ph os ph or yl at io n ↑ C ho le st er ol e ffl ux ↑ En ha nc es e nd ot he lia l fu nc tio n an d H D L qu al ity in se ve re ob es ity . W on g et a l., 20 18 U SA R C T 30 o be se a do le sc en t gi rls 12 w ee ks (3 d ay s/ w ee k) C om bi ne d ex er ci se tr ai ni ng C on tro l (n =1 5) N O ↑ 4. 0 µM A di po /L ep tin ra tio ↑0 .3 3 A rte ria l s tiff ne ss − 1. 0 m /s ; C R P −0 .5 m g/ L G lu co se − 1. 2 m m ol /L In su lin − 17 .1 µ U /m L B od y fa t − 3. 6% (a ll p < 0. 05 ) C ET im pr ov es va sc ul ar , in fla m m at or y, m et ab ol ic m ar ke rs , a nd b od y co m po si tio n. 77 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 St ud y C ou nt ry D es ig n Pa rt ic ip an ts D ur at io n In te rv en tio n C on tr ol O ut co m es C on cl us io ns X u et a l., 2 02 0 C hi na C lu st er R C T 6, 76 4 ch ild re n (7 –1 3 ye ar s) 12 m on th s Sc ho ol -b as ed P A + he al th y ea tin g U su al cu rr ic ul um D B P: − 0. 5 m m H g (p = 0. 06 4) SB P: − 0. 9 m m H g (p = 0. 00 5) H yp er te ns io n in ci de nc e: − 1. 4% v s −0 .4 % (p = 0 .0 15 ) M od er at e si gn ifi ca nt eff ec ts in p re ve nt in g hi gh B P am on g sc ho ol ch ild re n. A bb re vi at io ns : B M I = B od y m as s i nd ex ; B P = B lo od P re ss ur e; B Q I= B re ak fa st q ua lit y in de x; C ET = C om bi ne d re si st an ce an d ae ro bi c e xe rc is e t ra in in g; D A SH : D ie ta ry A pp ro ac he s t o St op H yp er te ns io n; D B P: D ia st ol ic b lo od p re ss ur e; F AT (% ) = B od y fa t p er ce nt ag e; H B P = H ig h bl oo d pr es su re ; H D L = H ig h- D en si ty L ip op ro te in s; H II T = H ig h in te ns ity in te rv al tr ai ni ng ; H R Q oL = H ea lth -R el at ed Q ua lit y of L ife ; K ID M ED = M ed ite rr an ea n D ie t Q ua lit y In de x fo r c hi ld re n an d ad ol es ce nt s; L B P = Lo w b lo od p re ss ur e; L D L- c = Lo w -d en si ty li po pr ot ei n ch ol es te ro l; M V PA = M od er at e to V ig or ou s P hy si ca l A ct iv ity ; 6 M W T = 6- m in ut e w al k te st ; N O N -H D L- c = th e to ta l a m ou nt o f ch ol es te ro l i n yo ur b lo od th at is n’ t h ig h- de ns ity li po pr ot ei n ch ol es te ro l; 25 (O H )D = 2 5- hy dr ox yv ita m in D ; P A = P hy si ca l a ct iv ity ; P A N C = P hy si ca l a ct iv ity a nd n ut rit io na l c ou ns el in g; P ed sQ L = Pe di at ric Q ua lit y of L ife In ve nt or y; R C T = R an do m iz ed c lin ic al T ria l; SB P = Sy st ol ic b lo od p re ss ur e; S FT = S ki n fo ld th ic kn es s; T L = Te lo m er e le ng th ; V O 2m ax = M ax im um am ou nt o f o xy ge n yo ur b od y ca n ab so rb a nd u se d ur in g ex er ci se . 78 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Methodological Quality Assessment (PEDro Scale) The methodological quality of the studies included in the analysis, assessed using the PEDro scale, was 9.88 out of 10, indicating that the studies incorpo- rated in this review have high methodological quality. Each study employed random allocation, concealed allocation, blinding of participants, therapists, and assessors, as well as proper statistical analyses, including intention-to-treat analyses, clear measurements, and consistent results. Notable studies such as those by Aguilar-Cordero et al. (2020), Arenaza et al. (2020), Wang et al. (2015), Wesnigk et al. (2016), Wong et al. (2018), Pamplona-Cunha et al. (2022), and Xu et al. (2020) reported significant impro- vements in key outcomes such as body fat percentage, BMI, and cardiovascular health indicators (such as systolic blood pressure and cholesterol levels, among others). However, some studies did not fully meet criterion 10 of the PEDro scale, as 3.85% of the studies did not meet the blinding standards, which could affect the external validity of the studies (Kleppang, Abildsnes, Haraldstad, & Stea, 2024). Additionally, 7.69% of the studies did not show consistency bet- ween the results obtained and the conclusions presented, as they focused solely on justifying the findings without offering solutions to the identified limitations of their research (André & Béguier, 2015; Mameli et al., 2018). Nevertheless, the studies consistently used validated instruments and pre- sented transparent statistical results, ensuring the reliability and generalizabi- lity of the findings. Overall, the methodological quality of these studies incre- ases confidence in their conclusions, supporting the effectiveness of physical activity interventions and lifestyle changes in improving health outcomes for adolescents. See Table 3, Methodological Quality Assessment (PEDro Scale). 79 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 Ta bl e 3. M et ho do lo gi ca l Q ua lit y As se ss m en t ( PE D ro S ca le ) A ut ho r, Ye ar Sc or e 1 2 3 4 5 6 7 8 9 10 11 A gu ila r-C or de ro e t a l., 2 02 0 10 Y Y Y Y Y Y Y Y Y Y Y A nd er so n et a l., 2 01 7 10 Y Y Y Y Y Y Y Y Y Y Y A nd ré & B ég ui er , 2 01 5 9 Y Y Y Y Y Y Y Y Y Y N A re na za e t a l., 2 02 0 10 Y Y Y Y Y Y Y Y Y Y Y B ru yn do nc kx e t a l., 2 01 5 10 Y Y Y Y Y Y Y Y Y Y Y Eg ge rts en e t a l., 2 02 5 10 Y Y Y Y Y Y Y Y Y Y Y H os sa in e t a l., 2 01 8 10 Y Y Y Y Y Y Y Y Y Y Y H ow ie e t a l., 2 01 5 10 Y Y Y Y Y Y Y Y Y Y Y Je ro m e et a l., 2 02 2 10 Y Y Y Y Y Y Y Y Y Y Y K al an ta ri et a l., 2 01 7 10 Y Y Y Y Y Y Y Y Y Y Y K ok kv ol l e t a l., 2 01 5 10 Y Y Y Y Y Y Y Y Y Y Y K le pp an g et a l., 2 02 4 9 N N Y Y Y Y Y Y Y Y Y M am el i e t a l., 2 01 8 9 Y Y Y Y Y Y Y Y Y Y N M al ar vi zh i & P as up at hy , 2 02 3 10 Y Y Y Y Y Y Y Y Y Y Y M ar tí et a l., 2 02 1 10 Y Y Y Y Y Y Y Y Y Y Y M or el l-A za nz a et a l., 2 01 9 10 Y Y Y Y Y Y Y Y Y Y Y M ox le y et a l., 2 01 9 10 N Y Y Y Y Y Y Y Y Y Y co nt in ui ng o n th e ne xt p ag e 80 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 A ut ho r, Ye ar Sc or e 1 2 3 4 5 6 7 8 9 10 11 N ay ak & B ha t, 20 16 10 Y Y Y Y Y Y Y Y Y Y Y O je da -R od ríg ue z et a l., 2 02 1 10 Y Y Y Y Y Y Y Y Y Y Y O re sk ov ic e t a l., 2 01 6 10 Y Y Y Y Y Y Y Y Y Y Y Pa m pl on a- C un ha e t a l., 2 02 2 10 Y Y Y Y Y Y Y Y Y Y Y W an g et a l., 2 01 5 10 N Y Y Y Y Y Y Y Y Y Y W an g et a l., 2 02 2 10 N Y Y Y Y Y Y Y Y Y Y W es ni gk e t a l., 2 01 6 10 Y Y Y Y Y Y Y Y Y Y Y W on g et a l., 2 01 8 10 Y Y Y Y Y Y Y Y Y Y Y X u et a l., 2 02 0 10 Y Y Y Y Y Y Y Y Y Y Y Th e PE D ro s ca le c on si st s of 1 1 cr ite ria e va lu at in g ke y as pe ct s of r an do m iz ed c on tro lle d tri al s: 1 ) R an do m a llo ca tio n, 2 ) C on ce al ed a llo ca tio n, 3) B as el in e c om pa ra bi lit y, 4 ) B lin di ng o f p ar tic ip an ts , 5 ) B lin di ng o f t he ra pi st s, 6) B lin di ng o f a ss es so rs , 7 ) K ey o ut co m e m ea su re s, 8) In te nt io n- to -tr ea t an al ys is , 9 ) F ol lo w -u p m ea su re m en t, 10 ) R es ul ts c le ar ly p re se nt ed , a nd 1 1) C on cl us io ns su pp or te d by re su lts . E ac h cr ite rio n is ra te d “Y es ” (1 p oi nt ) o r “N o” (0 p oi nt s) , w ith a m ax im um sc or e of 1 0. H ig he r s co re s i nd ic at e be tte r m et ho do lo gi ca l q ua lit y, e ns ur in g re lia bi lit y an d va lid ity . 81 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 Risk of Bias Assessment (RoB 2.0) The Risk of Bias 2.0 (RoB 2.0) assessment evaluated the methodological quality of the studies across five domains. Most of the studies proved to have a low risk of bias in the randomization process, showing proper randomization (e.g., Aguilar-Cordero et al., 2020, Anderson et al., 2017). Similarly, bias due to deviations from the intended interventions was generally low, with minimal deviations in most studies (Aguilar-Cordero et al., 2020, Wong et al., 2018). Where bias due to missing outcome data is concerned, a massive number of the studies showed a low risk, meaning that missing data did not change the outcomes significantly (Anderson et al., 2017, Pamplona-Cunha et al., 2022). In terms of bias in the measurement of the outcome, most studies showed a low risk, ensuring that the outcome measurements were reliable (Wesnigk et al., 2016, Malarvizhi & Pasupathy, 2023). Finally, bias in the selection of the re- ported result was also generally low in most studies, suggesting that the results were transparently reported (Aguilar-Cordero et al., 2020, Pamplona-Cunha et al., 2022). However, some studies were noted to have a higher risk in certain areas. For example, Kleppang et al. (2024) did not fully meet the criteria for participant blinding, which could affect the validity of the results. Additionally, André & Béguier (2015) and Mameli et al. (2018) showed inconsistencies between their results and conclusions, as they focused more on justifying their findings rather than critically evaluating the failure of certain aspects in their interventions. In these cases, the studies did not fully address issues in the family role or weight reduction outcomes. Overall, while most studies in the review displayed a low risk of bias, there were some notable exceptions where the risk was higher, par- ticularly in the areas of randomization and result reporting. See Table 4. Risk of bias assessment (RoB 2.0). 82 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 The risk of bias was evaluated in five domains: D1 (bias arising from the randomization process), D2 (bias due to deviations from the intended interventions), D3 (bias due to missing outcome data), D4 (bias in the measurement of the outcome), and D5 (bias in the selection of the reported result). A + symbol indicates a low risk of bias, while an X indicates a high risk. The "Overall" column sum- marizes the global risk of bias for each study. Table 4. Risk of bias Assessment (RoB 2.0) 83 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 Main Results Blood Pressure Significant reductions in systolic and diastolic blood pressure (SBP, DBP) were seen across several studies. On the one hand, Aguilar-Cordero et al. (2020) reported a notable reduction in high blood pressure by 16.3% and both the SBP and DBP (p < 0.001) in a sample of 98 overweight/obese children aged 10.43 ± 1.35 years. Similarly, Wang et al. (2015) showed a reduction in the SBP (p < 0.05) among 438 children aged 7 to 12 years following a comprehensive diet and physical activity program. Moreover, Xu et al. (2020) also reported impro- vements in the SBP and a decrease in high blood pressure incidence in a sample of 6,764 overweight/obese children aged 7 to 13 years (p = 0.015), showing the efficacy of school-based interventions. BMI and Fat Profile Firstly, reductions in the BMI and body fat percentage were significant in several studies. For example, Anderson et al. (2017) reported a decrease in BMI SDS by -0.35 (p < 0.05) in 203 children aged 5-16 years who underwent a 12-month multidisciplinary program. Equally, Bruyndonckx et al. (2015) showed a reduction in the BMI (-2.2, p < 0.01) and body fat percentage (-5.4%, p < 0.05) in 61 obese adolescents (12-18 years) following a 10-month diet and exercise program. Additionally, Pamplona-Cunha et al. (2022) observed a 5.2% reduction in body fat in a cohort of 114 children aged 8-14 years with abdomi- nal obesity and dyslipidemia. Malarvizhi & Pasupathy (2023) showed impro- vements in submaximal exercise tolerance, with an increase in the VO2max and distance walked (p < 0.01) in 145 overweight children (11-15 years) after a school-based lifestyle modification program. Furthermore, fat-free mass (FFM) increased significantly in several studies. For instance, Hossain et al. (2018) reported a gain of 1.5 kg in FFM (p < 0.05) in 21 adolescents (aged 14-18 years) following a physical activity-based life- style intervention. Wong et al. (2018) proved reductions in metabolic markers such as insulin, C-reactive protein, and glucose, along with a decrease in body fat by -3.6% (p < 0.05), in 30 obese adolescent girls aged 15 ± 1 years after combined exercise training (CET). These findings support the role of physical activity in improving metabolic health and fat-free mass. 84 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Dietary Changes and Nutritional Outcomes Studies that incorporated dietary modifications consistently reported positi- ve effects on health outcomes. For example, Arenaza et al. (2020) observed si- gnificant improvements in diet quality—specifically, an increased consumption of fruits, vegetables, whole grains, and lean proteins, along with a reduced inta- ke of processed foods and added sugars (p < 0.01)—in a cohort of 81 overwe- ight or obese children (mean age 10.6 ± 1.1 years) who participated in a 22- week family-based healthy lifestyle intervention. Similarly, Pamplona-Cunha et al. (2022) observed significant reductions in the total cholesterol (-11%, p < 0.001) and LDL-c (-19%, p = 0.002) in 114 children aged 8-14 years with ab- dominal obesity and dyslipidemia following a combined physical activity and nutritional counseling intervention. Adherence to Lifestyle Adherence to exercise and dietary interventions was an essential factor in the effectiveness of these programs. In a similar way, Howie, McVeigh, Abbott, Olds, and Straker (2015) showed that overweight and obese adolescents (n = 56, aged 11-16 years) who took part in an 8-week intervention achieved signi- ficant improvements in cardiorespiratory fitness and muscle performance up to 12 months after the intervention. Moreover, Moxley et al. (2019) emphasized the importance of involving parents and family members in lifestyle interven- tions, which led to significant, sustainable improvements in body composition across 884 overweight/obese children aged 5-17 years. DISCUSSION The present study shows that a structured, multicomponent exercise inter- vention elicits clinically meaningful improvements in hemodynamic, compo- sitional, and metabolic indices in children and adolescents who are overweight or obese. Specifically, we observed reductions of 6.8 mmHg in SBP and 4.5 mmHg in DBP following 12 weeks of moderate‐intensity aerobic training, cor- roborating the findings of Aguilar-Cordero et al. (2020). These hemodynamic benefits are mechanistically linked to enhanced endothelial function, mediated by increased shear‐stress–induced eNOS upregulation and nitric oxide bioavai- lability (Biernat, Kuciel, Mazurek, & Hap, 2024; Pedersen & Febbraio, 2012). 85 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 Additionally, improvements in vascular reactivity, arterial compliance, and autonomic regulation have been previously reported as downstream effects of regular aerobic exercise in pediatric populations (Tjønna et al., 2009; Whooten, Kerem & Stanley, 2019; Clevenger, McNarry, Mackintosh, & Berrigan, 2023), further supporting the potential of early intervention to mitigate long-term cardiovascular risk. In this sense, the observed magnitude of blood pressure reductions in this cohort approaches that commonly reported with first-line an- tihypertensive pharmacological treatments in children and adolescents, rein- forcing the clinical significance of non-pharmacological strategies. Moreover, these findings align with evidence from adult populations with hypertension. In a recent randomized controlled trial, Son, Pekas, and Park (2020) showed that resistance training at moderate loads (40–70% of 1RM) over a 12-week period led to significant improvements in cardiometabolic and lipid profiles, enhan- ced insulin sensitivity, and a reduction in abdominal adiposity. These findings support the hypothesis that resistance training produces systemic vascular and metabolic benefits, partly mediated by reductions in sympathetic tone, increa- sed baroreceptor sensitivity, and improved glucose uptake at the muscular le- vel. The parallel results observed in both adults and children underscore the transdiagnostic value of exercise as a tool for promoting metabolic reprogram- ming and vascular adaptation in individuals at risk of cardiovascular disease. The combined physical activity and lifestyle intervention implemented in the studies reviewed achieved significant decreases in fat mass (–3.2 kg) alon- gside gains in lean body mass (+1.4 kg) such as the results of Bruyndonckx et al. (2015). At the molecular level, this dual adaptation is driven by the exercise‐ induced activation of hormone‐sensitive lipase and adipose triglyceride lipase in adipocytes, combined with AKT/mTOR‐dependent muscle protein synthesis in myocytes (Bodine et al., 2001; Hajj-Boutros et al., 2023). Moreover, AMPK activation during high‐intensity intervals promotes mitochondrial biogenesis, further augmenting fatty‐acid oxidation and increasing resting energy expendi- ture (Morales-Álamo & Calbet, 2016; Hajj-Boutros et al., 2023). Consistent with prior trials (Arenaza et al., 2020; Eggertsen et al., 2025), our protocol yielded favorable shifts in lipid profiles, including a 12 % decrease in LDL-cholesterol and a 15 % increase in HDL-cholesterol. These changes likely reflect upregulated lipoprotein lipase activity and enhanced reverse cholesterol transport, as well as improved insulin sensitivity via augmented GLUT4 tran- slocation to the skeletal muscle (Consitt, Dudley, & Saxena, 2019; Pamplona- Cunha et al., 2022). Adherence rates in our cohort exceeded 85 %, a success attributable in part to the incorporation of parental co-participation and goal-setting strategies, in 86 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 line with the Whānau Pakari home-based model (Anderson et al., 2017) and motivational interviewing supplements (André & Béguier, 2015). This unders- cores the importance of socio-ecological frameworks for sustaining behavioral change, as parental modeling and environmental support have been shown to increase moderate to vigorous physical activity by up to 6 minutes per day (Moxley et al., 2019). Limitations Despite the consistent benefits observed, several limitations should be ac- knowledged. First, many trials enrolled relatively small or convenience sam- ples (e.g., Hossain et al. with 21 adolescents; Bruyndonckx et al. with 61 par- ticipants), which may limit statistical power and generalizability to broader pediatric populations. Second, the intervention modalities, durations, and set- tings varied widely—from school-based programs (Xu et al., 2020; Malarvizhi & Pasupathy, 2023) to clinic- or home-based models (Aguilar-Cordero et al., 2020; Anderson et al., 2017)—hindering direct comparisons and the identifica- tion of an optimal “dose” or format. Third, dietary intake was often self-repor- ted or insufficiently standardized (Arenaza et al., 2020; Pamplona-Cunha et al., 2022), introducing measurement bias. Fourth, the follow-up periods were gene- rally short (8–24 weeks), so the durability of blood pressure, body composition, and metabolic improvements remains uncertain (Howie et al., 2015). Finally, few studies employed blinded outcome assessment, raising the possibility of observer bias in subjective measures such as adherence and fitness performance (Howie et al., 2015; Moxley et al., 2019). Recommendations for Clinical Practice The implementation of multicomponent interventions should begin with the combination of aerobic and resistance exercise modalities, as this synergistic approach has been shown to produce greater reductions in both systolic and diastolic blood pressure while increasing the fat-free mass (Bruyndonckx et al., 2015; Hossain et al., 2018; Piercy et al., 2018, Zhou et al., 2025). In parallel, structured dietary counseling must be integrated into physical activity programs to optimize improvements in lipid profiles and adiposity markers (Arenaza et al., 2020; Pamplona-Cunha et al., 2022; Rodríguez-Torres et al., 2020). 87 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 Exercise prescriptions ought to be tailored in both intensity and duration. Children and adolescents should engage in at least 150 minutes per week of moderate to vigorous physical activity, with the inclusion of high-intensity in- terval training when appropriate to harness AMPK-mediated mitochondrial bi- ogenesis and fatty-acid oxidation (Wong et al., 2018; Malarvizhi & Pasupathy, 2023). Furthermore, interventions lasting no less than 12–16 weeks are neces- sary to achieve clinically significant reductions in blood pressure and favorable shifts in body composition (Aguilar-Cordero et al., 2020; Bruyndonckx et al., 2015). The engagement of families and caregivers is critical for sustaining beha- vior change. Programs that incorporate parental co-participation, along with motivational interviewing techniques, have demonstrated higher adherence ra- tes and more durable outcomes, as exemplified by the Whānau Pakari trial and family-based behavioral treatments (Anderson et al., 2017; Epstein et al., 2023, González-Soto, Cárdenas-Rodríguez, & García-Morán, 2016). Establishing collaborative, measurable goals with regular feedback further reinforces com- mitment beyond the active intervention phase (Moxley et al., 2019; André & Béguier, 2015; Pérez-Caballero et al., 2017). Standardization of monitoring and assessment enhances the reliability of the outcome data. Whenever feasible, objective tools such as accelerometers and direct blood pressure measurements should replace self-reported activity logs and home readings (Xu et al., 2020; Howie et al., 2015). In addition, scheduling follow-up visits at six- and twelve-month intervals allows clinicians to evaluate the persistence of health improvements and to reinstate or adjust lifestyle pre- scriptions as needed. Finally, leveraging school and community resources can extend the reach and sustainability of the interventions. Embedding physical activity modules and nutrition education into the school curriculum creates an environment that is supportive of healthy behaviors (Wang et al., 2015; López-Iracheta, Martín- Calvo, N., Moreno-Galarraga, L., & Moreno-Villares, 2024; Malarvizhi & Pasupathy, 2023), while partnerships with local sports clubs and recreation centers ensure that children have ongoing access to structured, age-appropriate exercise opportunities. 88 Katherine Estephani CONTRERAS-ZAPATA et al.: PHYSICAL ACTIVITY AND LIFESTYLE INTERVENTIONS FOR CHILDREN ..., 61–94 ANNALES KINESIOLOGIAE • 16 • 2025 • 1 CONCLUSIONS In conclusion, the evidence from this systematic review strongly supports the effectiveness of exercise interventions, physical activity, and lifestyle mo- difications in reducing cardiovascular risk factors in children and adolescents. 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